Saad - Osteoarthritis part 2 Flashcards
aside from GI , name 2 other potential NSAID toxicities
Cardiovascular
renal
how do NSAIDS have CV toxicity concern
they can increase blood pressure and exacerbate congestive heart failure
seen with all NSAIDS used chronically (naproxen may be least harmful)
chronic use of NSAIDS have increased risk of CV events
which NSAID may be the least harmful in this regard?
naproxen
Explain the risk/benefit of NSAIDS and CV toxicity
the overall risk is small – however if it does happen could be life threatening
benefit is relief of pain
NSAIDS are contraindicated before and after _____ surgery
CABG
coronary artery bypass graft
NSAIDS being used with what 2 classes of drugs has renal toxicity concern? explain
NSAIDS + ACE inhibitors or diuretics
can reduce blood flow to kidneys and cause toxicity
name a sulfonamide NSAID that must be avoided in patients allergic to sulfa
celecoxib
true or false
NSAIDS should be avoided in the renally impaired
true
name 2 hypersensitivity reactions of NSAIDS
rash, bronchospasm
*** what is the NSAID only approved for SHORT TERM USE?
WHY?
how long?
ketorolac
less than or equal to 5 days
it is extremely potent – thus has the most GI, renal, CV side effects
give to patients requiring opioid-like pain relief
NSAIDS with _____ and ________ cause more GI side effects
a long half life
extended release dosage form
name the 3 systems that are a concern for toxicity when taking NSAIDS
GI
CV
kidney
explain the NSAID + ASA (aspirin) interaction
NSAIDS block COX1 – aspirin cant access
ONLY if NSAID is taken before aspirin
NSAIDS block the antiplatelet effects of aspirin (if taken before) – have reversible and variable antiplatelet effect
**important:
when should ibuprofen and aspirin be taken to avoid interaction
take aspirin 30 mins BEFORE ibuprofen
if pt already took ibuprofen, have to wait at least 8 hours to take the aspirin – so that COX1 isnt blocked by it
true or false
opioids are 1st line and used for initial management of OA pain
false
risk of abuse – OA is chronic
not used for initial management
when may opioids be useful in OA patients?
those who dont get much relief from NSAIDS, aspirin, intra articular injections or topical therapy
(or they cant tolerate side effects)
true or false
data on opioids fails to demonstrate a clear benefit for chronic pain
true
do opioids and tramadol have the same side effects?
yes - but lower abuse potential and tramadol less potent
tramadol is contraindicated during or within 14 days following _________ therapy or other medication with __________ activity.
why?
MAO inhibitor
or other med with serotonin activity
risk of serotonin syndrome
true or false
tramadol is available as a stand alone and with acetaminophen
true
true or false
tramadol requires dose adjustment in renal failure
true (max 200mg a day)
max daily dose tramadol with normal renal function
400mg
what DEA class is tramadol
schedule 4 control
name some tramadol adverse effects
CNS depression
drowsiness, dizziness
constipation
resp depression
tolerance
addiction
tramadol should be given with caution if the patient is taking….
meds that lower the seizure threshold
true or false
duloxetine and tramadol should be given with caution
true
serotonin syndrome risk
name 2 topical OA therapies
capsaicin
diclofenac (voltaren)
TRUE OR FALSE
topical OA therapies cannot be used in combination with other pharmacologic therapies for OA
FALSE - they can
name an advantage that topical therapies have over oral for OA
ppl unable to tolerate oral NSAIDS bc GI/renal/cardiac side effects can take
How does capsaicin work to reduce pain
depeletes substance P - neurotransmitter
in which OA areas are capsaicin most effective?
in which joint is it least effective?
most effective in hands and knees
not very for hip
in which area should capsaicin definitely not be applied
any mucous membranes - severe burning
is capsaicin recommended for initial management of OA pain?
no - but can be used if other treatments fail
what is an advantage of capsaicin over other pain relief OA therapies
no systemic adverse effects
how long does capsaicin take to give analgesic effect after applied?
3-5 days
*will burn initially
may take several weeks for MAXIMAL effect
how many times a day is capsaicin applied
3-4 times
explain how you would counsel a patient on how to use capsacin
wear gloves and avoid cutaneouos/mucus membranes
may take 3-5 days to work, will burn at first, up to several weeks to see max effect
are topical NSAIDS systemically absorbed?
minimal-none
the ACR strongly recommends topical rather than oral NSAIDS for which age range?
greater than or equal to 75 years
the efficacy of topical NSAIDS has been observed in which 2 kinds of OA?
knee and hand
diclofenac gel/solution/patches typically requires ____ times daily dosing
4
name an NSAID that can be compounded to be topically applied
ketoprofen
what was the theory of using hyaluronic acid in OA patients
thought was that they would act as a shock absorber in synovial fluid and provide elasticity
-efficacy is questionable and response is very variable
ACR conditionally recommends against the use of intrarticular hylauronic acid in ______ OA and STRONGLY recommended against it in ____ OA
knee
hip
what is an advantage of IA hyaluronic acid over other agents
avoiding systemic side effects
many hyaluronic acid injections are contraindicated in patients with what allergy?
avian (bird)
besides patients with avian allergies, where else is IA hyaluronic acid contraindicated
in an infected joint space
explain the clinical evidence of hylauronic acid in OA patients
cannot be confirmed
response seems to be variable, efficacy is questionable. may just be placebo effect
question of whether the mass influences efficacy
what are some adverse effects of intra articular hyaluronic acid injections
local pain, itching, joint swelling, ecchymosis (bruise)
are intra-articular STEROIDS beneficial in OA patients?
yes - for acute flares, effusion, and severe OA
TRUE OR FALSE
oral and intra-articular steroids have use in OA patients
FALSE - only intra-articular
as mentioned, intra-articular steroid injections can be used in OA patients in cases of localized effusions
what is a consideration with this?
the fluid must be aspirated before injecting if there is an effusion
repeated intra-articular steroid injections may cause…..
bone loss and/or tendon rupture
the dose of intra-articular steroid injections depends on what
the size of the joint
localized side effects of intra-articular steroid injection
localized inflammatory reaction
what would you tell a pt getting intra articular steroid
include how long it may take to work and what to avoid
should begin in 2-3 days and last 4-8 weeks
avoid straining the joint a few weeks after injection
name some SYSTEMIC side effects of intra articular steroids
edema, inc BP, hyperglycemia, dyspepsia, hypercorticolism
does the ACR recommend glucosamine/chondroitin for OA?
ACR really only mentions chondroitin as conditionally rec for hand OA but strongly rec AGAINST in knee/hip.
but it’s mainly sold as a combination product with glucosamine
how is glucosamine/chrondroitin thought to work in OA patients
it stimulates proteoglycan synthesis from articular cartilage – help maintain hydrostatic pressure depsite the compressiong pressure
glucosamine - “building block” for cartialge
chondroitin sulfate “water magnet” in cartilage
what is an advantage of glucosamine/chondroitin over oral NSAIDS
can avoid the GI/CV systemic side effects in pts predisposed to these – safer
explain the effectiveness of glucosamine/chondroitin over an NSAID like celecoxib
in a study, combo was not better than celecoxib at relieving pain
name some AE of glucosamine/chondroitin
mild GI discomfort like gas and bloating
________________ should be avoided in SHELLFISH ALLERGY
glucosamine
__________ should be avoided in cattle, shark, pink allergy
chondroitin
if glucosamine/chondroitin will show effect, how long will it take
4-8 weeks
why are glucosamine/chondroitin studies not reliable (aside from placebo effect)
they only measure patient symptoms and no changes in morphology
what are DMOADS
disease modifying OA drugs
name a supplement that may be just as effective as oral NSAIDS in OA patients
turmeric
